From morbidity reduction to cost-effectiveness: Enhanced recovery after surgery (ERAS) society recommendations in minimal invasive liver surgery.

PURPOSE: Minimal-invasive liver surgery (MILS) reduces surgical trauma and is associated with fewer postoperative complications. To amplify these benefits, perioperative multimodal concepts like Enhanced Recovery after Surgery (ERAS), can play a crucial role. We aimed to evaluate the cost-effectiveness for MILS in an ERAS program, considering the necessary additional workforce and associated expenses. METHODS: A prospective observational study comparing surgical approach in patients within an ERAS program compared to standard care from 2018-2022 at the Charité - Universitätsmedizin Berlin. Cost data were provided by the medical controlling office. ERAS items were applied according to the ERAS society recommendations. RESULTS: 537 patients underwent liver surgery (46% laparoscopic, 26% robotic assisted, 28% open surgery) and 487 were managed by the ERAS protocol. Implementation of ERAS reduced overall postoperative complications in the MILS group (18% vs. 32%, p = 0.048). Complications greater than Clavien-Dindo grade II incurred the highest costs (€ 31,093) compared to minor (€ 17,510) and no complications (€13,893; p < 0.001). In the event of major complications, profit margins were reduced by a median of € 6,640. CONCLUSIONS: Embracing the ERAS society recommendations in liver surgery leads to a significant reduction of complications. This outcome justifies the higher cost associated with a well-structured ERAS protocol, as it effectively offsets the expenses of complications.

Clinical and economic comparison of laparoscopic versus open hepatectomy for primary hepatolithiasis: a propensity score-matched cohort study.

BACKGROUND: It is unclear whether laparoscopic hepatectomy (LH) for hepatolithiasis confers better clinical benefit and lower hospital costs than open hepatectomy (OH). This study aim to evaluate the clinical and economic value of LH versus OH. METHODS: Patients undergoing OH or LH for primary hepatolithiasis at Yijishan Hospital of Wannan Medical College between 2015 and 2022 were divided into OH group and LH group. Propensity score matching (PSM) was used to balance the baseline data. Deviation-based cost modelling and weighted average median cost (WAMC) were used to assess and compare the economic value. RESULTS: A total of 853 patients were identified. After exclusions, 403 patients with primary hepatolithiasis underwent anatomical hepatectomy (OH n=143; LH n=260). PSM resulted in 2 groups of 100 patients each. Although LH required a longer median operation duration compared with OH (285.0 versus 240.0 min, respectively, P<0.001), LH patients had fewer wound infections, fewer pre-discharge overall complications (26 versus 43%, respectively, P=0.009), and shorter median postoperative hospital stays (8.0 versus 12.0 days, respectively, P<0.001). No differences were found in blood loss, major complications, stone clearance, and mortality between the two matched groups. However, the median overall hospital cost of LH was significantly higher than that of OH (CNY¥52,196.1 versus 45,349.5, respectively, P=0.007). Although LH patients had shorter median postoperative hospital stays and fewer complications than OH patients, the WAMC was still higher for the LH group than for the OH group with an increase of CNY¥9,755.2 per patient undergoing LH. CONCLUSION: The overall clinical benefit of LH for hepatolithiasis is comparable or even superior to that of OH, but with an economic disadvantage. There is a need to effectively reduce the hospital costs of LH and the gap between costs and diagnosis-related group reimbursement to promote its adoption.

Laparoscopic liver resection for hepatocellular carcinoma presents less respiratory complications compared with open procedure: A propensity score analysis in the elderly.

BACKGROUND: Resection is still the most efficacious treatment to hepatocellular carcinoma (HCC), among which laparoscopic liver resection (LLR) have controversial effects against conventional open procedure (OLR). With a predictable aging tendency of population worldwide, conventional surgical procedures need to be modified to better accommodate elderly patients. Here, we designed a retrospective study based on propensity score analysis, aiming to compare the efficacy of OLR and LLR in patients over 65 years. METHODS: We retrospectively analyzed patients with an age over 65 who underwent liver resection between January 2015 and September 2018. Patients were divided into the LLR group and OLR group. Short-term and long-term outcomes were compared before and after 1:1 propensity score matching. RESULTS: Among 240 enrolled patients, 142 were matched with comparable baseline (71 each group). In the matched cohort, LLR group presented with shorter postoperative hospital stay (median 7 vs 6 days, p = 0.003) and fewer respiratory complications (19.7% vs. 7.0%, p = 0.049), especially pleural effusion (15.5% vs. 2.8%, p = 0.020). Meanwhile, LLR had comparable overall hospital cost (6142 vs. 6243 USD, p = 0.977) compared with OLR. The overall survival (OS) and disease-free survival (DFS) did not differ in the two groups. CONCLUSIONS: Our study showed that laparoscopic liver resection for HCC in the older age groups is associated with shorter postoperative hospital stay and comparable hospital cost compared with open procedure, which could be attributable to less respiratory complications. We recommend that laparoscopy be taken as a priority option for elderly patients with resectable HCC.

Hepatopancreatic Surgery in the Rural United States: Variation in Outcomes at Critical Access Hospitals.

BACKGROUND: Sixty million Americans live in rural America, with roughly 17.5% of the rural population being 65 y or older. Outcomes and costs of Medicare beneficiaries undergoing hepatopancreatic surgery at critical access hospitals (CAHs) are not known. MATERIALS AND METHODS: Medicare files were used to identify patients who underwent hepatopancreatic resection. Outcomes were compared (CAHs versus non-CAHs). RESULTS: Patients undergoing hepatopancreatic surgery at non-CAHs versus CAHs had a similar comorbidity score (4 versus 5, P = 0.53). After adjusting for patient-level factors and procedure-specific volume, there was no difference in complication rate (adjusted odds ratio (aOR) 0.80, 95% confidence interval (CI) 0.52-1.24). The median cost of hospitalization was roughly $4000 less at CAHs than that at non-CAHs (P < 0.001). However, compared with patients undergoing surgery at non-CAHs, beneficiaries operated at CAHs had more than two times the odds of dying within 30 (aOR 2.45, 95% CI 1.42-4.2) and 90 d (aOR 2.28, 95% CI 1.4-3.71). CONCLUSIONS: Only a small subset of Medicare beneficiaries underwent hepatic or pancreatic resection at a CAH. Despite similar complication rate, Medicare beneficiaries undergoing surgery at a CAH had more than two times the odds of dying within 30 and 90 d after surgery.

Impact of cancer center accreditation on outcomes of patients undergoing resection for hepatocellular carcinoma: A SEER-Medicare analysis.

BACKGROUND: We sought to assess variations in outcomes among patients undergoing resection for hepatocellular carcinoma (HCC) at centers with varied accreditation status. METHODS: Patients undergoing resection for HCC from 2004 to 2016 were identified from the linked SEER-Medicare database. Short- and long-term outcomes as well as expenditures associated with receipt of surgery were examined based on cancer center accreditation. RESULTS: Among 1390 patients, 46.1% (n = 641) were treated at unaccredited centers, 39.3% (n = 546) at CoC-accredited and 14.6% (n = 203) at NCI-designated centers. Patients undergoing resection of HCC at NCI-designated hospitals had lower odds of complications (OR = 0.66, 95%CI: 0.45-0.98) and 90-day mortality (OR = 0.31, 95%CI: 0.11-0.85) after major liver resection compared with individuals treated at CoC-accredited centers. Receipt of surgery at NCI-designated hospitals (ref: CoC-accredited; HR = 0.81, 95%CI: 0.66-0.99) was an independent predictor of improved survival. Medicare payments for liver resection were comparable at different accreditation status centers (NCI: $21,760 vs CoC: $24,059 vs unaccredited: $24,724, p = 0.18). CONCLUSION: Patients undergoing resection of HCC at NCI-designated hospitals had improved outcomes for the same level of Medicare expenditure compared with patients treated at CoC-accredited centers.

Laparoscopic partial hepatectomy is cost-effective when performed in high volume centers: A five state analysis.

BACKGROUND: Prior studies comparing the efficacy of laparoscopic (LHR) and open hepatic resection (OHR) have not evaluated inpatient costs. METHODS: We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient Databases to identify patients undergoing hepatic resection between 2010 and 2014. RESULTS: 10,239 patients underwent hepatic resection. 865 (8%) underwent LHR and 9374 (92%) underwent OHR. On adjusting for hospital volume, patients undergoing LHR had a lower risk of respiratory (OR 0.64, 95% CI [0.52, 0.78]), wound (OR 0.48; 95% CI [0.29, 0.79]) and hematologic (OR 0.57; 95% CI [0.44, 0.73]) complication as well as a lower risk of being in the highest quartile of cost (0.58; 95% CI [0.43, 0.77]) than those undergoing OHR. Patients undergoing LHR in very high volume (>314 hepatectomies/year) centers had lower risk-adjusted 90-day aggregate costs of care than those undergoing OHR (-$8022; 95% CI [-$11,732, -$4311). DISCUSSION: Laparoscopic partial hepatectomy is associated with lower risk of postoperative complication than OHR. This translates to lower aggregate costs in very high-volume centers.

Analysis of economic impact of laparoscopic liver resection according to surgical difficulty.

INTRODUCTION: The advantages of laparoscopic liver resection (LLR) are well known, but their financial costs are poorly evaluated. The aim of this study was to analyze the economic impact of surgical difficulty on LLR costs, and to identify clinical factors that most affect global charges. METHODS: All patients who underwent LLR from 2014 to 2018 in a single French center were included. The IMM classification was used to stratify surgical difficulty, from group I through group III. The costing method was done combining top-down and bottom-up approaches. A multivariate analysis was performed in order to identify clinical factors that most affect global charges. RESULTS: Two hundred seventy patients were included (Group I: n = 136 (50%), Group II: n = 60 (22%), Group III: n = 74 (28%)). Total expenses significantly increased (p < 0.001) from Group I to Group III, but there was no difference regarding financial income (p = 0.133). Technical platform expenses significantly increased (p < 0.001) from Group I to Group III and represented the main expense among all costs with a total of 4 930 ± 2 601€. Among technical platform expenses, the anesthesia platform represented the main expense. In multivariate analysis, the four clinical factors that affected global charges in the whole study population were operating time (p < 0.001), length of stay (p < 0.001), admission in ICU (p < 0.001) and the occurrence of major complication (p < 0.05). An admission in ICU was the clinical factor that affected most global charges, as an ICU stay had a 39.1% increase effect on global charges in the whole study population. CONCLUSION: LLR is a cost-effective procedure. The more complex is the LLR, the higher is the hospital cost. An admission in ICU was the clinical factor that most affected global charges.

Comparative clinical outcomes of robot-assisted liver resection versus laparoscopic liver resection: A meta-analysis.

BACKGROUND: As an emerging technology, robot-assisted surgical system has some potential merits in many complicated endoscopic procedures compared with laparoscopic surgery. But robot-assisted liver resection is still a controversial problem on its advantages compared with laparoscopic liver resection. We aimed to perform the meta-analysis to assess and compare the clinical outcomes of robot-assisted and laparoscopic liver resection. METHODS: We searched PubMed, Cochrane Library, Embase databases, Clinicaltrials, and Opengrey through March 24, 2020, including references of qualifying articles. English-language, original investigations in humans about robot-assisted and laparoscopic hepatectomy were included. Titles, abstracts, and articles were reviewed by at least 2 independent readers. Continuous and dichotomous variables were compared by the weighted mean difference (WMD) and odds ratio (OR), respectively. RESULTS: Of 936 titles identified in our original search, 28 articles met our criteria, involving 3544 patients. Compared with laparoscopy, the robot-assisted groups had longer operative time (WMD: 36.93; 95% CI, 19.74-54.12; P < 0.001), lower conversion rate (OR: 0.63; 95% CI, 0.46-0.87; P = 0.005), higher transfusion rate (WMD: 2.39; 95% CI, 1.51-3.76; P < 0.001) and higher total cost (WMD:0.49; 95% CI, 0.42-0.55; P < 0.001). In addition, the baseline characteristics of patients about largest tumor size was larger (WMD: 0.36; 95% CI, 0.16-0.56; P < 0.001) and malignant lesions rate was higher (WMD: 1.50; 95% CI, 1.21-1.86; P < 0.001) in the robot-assisted versus laparoscopic hepatectomy. The subgroup analysis of minor hepatectomy showed robot-assisted was associated with longer operative time (WMD: 36.00; 95% CI, 12.59-59.41; P = 0.003), longer length of stay (WMD: 0.51; 95% CI, 0.02-1.01; p = 0.04) and higher total cost (WMD: 0.48; 95% CI, 0.25-0.72; P < 0.001) (Table 3); while the subgroup analysis of major hepatectomy showed robot-assisted was associated with lower estimated blood loss (WMD: -122.43; 95% CI, -151.78--93.08; P < 0.001). CONCLUSIONS: Our meta-analysis revealed that robot-assisted was associated with longer operative time, lower conversion rate, higher transfusion rate and total cost, and robot-assisted has certain advantages in major hepatectomy compared with laparoscopic hepatectomy.

Laparoscopic hepatectomy is safe and effective for the management of patients with colorectal cancer liver metastases in a population-based analysis in Ontario, Canada. A retrospective cohort study.

BACKGROUND: Laparoscopic hepatectomy (LH) has been deemed safe, and, in the case of minor hepatectomy, the standard of care. Short-, long-term outcomes and costs of LH compared with open hepatectomy (OH) in patients with colorectal cancer liver metastases have not been well described at the population level. MATERIALS AND METHODS: Patients diagnosed with colorectal cancer undergoing hepatectomy were included in this population-based retrospective cohort study from 2006- to 2014. Postoperative complications (per Clavien-Dindo) and survival were analyzed using a linear mixed model and Cox-Proportional hazards model respectively. Costs of surgery and the 90-day postoperative period were considered in 2018 Canadian dollars and compared from the perspective of a third-party payer. RESULTS: Over a median follow-up of 56 months, 95% confidence interval (CI): 51 to 68), there were 2991 hepatectomies (OH: 2551 (85%) and LH: 440 (15%)). LH compared to OH was more common for patients >70 years-old (30% vs. 22%, p = 0.004) and for minor hepatectomy (52% vs. 32%, p < 0.001) respectively. By multivariable analyses, OH was associated with similar 90-day mortality (Odds Ratio (OR) 1.05, 95% CI: 0.56-1.97), and overall survival (Hazard Ratio (HR) 1.08, 95% CI: 0.90-1.29), but higher rates of major postoperative complications (OR 1.34, 95% CI: 1.03-1.76), higher cost (median difference $6,163, 95% CI: $3229 to $9096), and longer length of hospital stay (LOS) (mean difference 3.04 days, 95% CI: 2.7 to 3.91). CONCLUSION: LH was associated with lower postoperative complications, shorter LOS, which translated into lower costs to the healthcare system, without differences in postoperative mortality and survival.

Sociodemographic Characteristics as Predictors of Outcomes in Hepatocellular Carcinoma: A Retrospective Cohort Study.

BACKGROUND: Race, gender, insurance status, and income play important roles in predicting health care outcomes. However, the impact of these factors has yet to be fully elucidated in the setting of hepatocellular carcinoma (HCC). METHODS: We designed a retrospective cohort study utilizing data from the Surveillance, Epidemiology, and End Results (SEER) program to identify patients diagnosed with resectable HCC (N = 28,518). Demographic factors of interest included race (Asian/Pacific Islander [API], African American [AA], Native American/Alaska Native [NA], or White [WH]) and gender (male [M] or female [F]). Insurance classifications included those having Medicare/Private Insurance [ME/PI], Medicaid [MAID], or No Insurance [NI]. Median household income was estimated for all diagnosed with HCC. Endpoints included: (1) overall survival; (2) likelihood of receiving a recommendation for surgery; and (3) specific surgical intervention performed. Multivariate multinomial logistic regression for relative risk ratio (RRR) and Cox regression models were used to identify pertinent associations. RESULTS: Race, gender, insurance status, and income had statistically significant effects on the likelihood of surgical recommendation and overall survival. API were more likely to receive a recommendation for hepatic resection (RRR = 1.45; 95% CI: 1.31-1.61; Reference Race: AA) and exhibited prolonged overall survival (HR = 0.77; 95% CI: 0.73-0.82; Reference Race: AA) as compared to members of any other ethnic group; there was no difference in these endpoints between AA, NA, or WH individuals. Gender also had a significant effect on survival: Females exhibited superior overall survival (HR = 0.89; 95% CI: 0.85-0.93; Reference Gender: M) as compared to males. Patients who had ME/PI were more likely than those with MAID or NI to receive a surgical recommendation. ME/PI was also associated with superior overall survival. Conclusions: Race, gender, insurance status, and income have measurable effects on HCC management and outcomes. The underlying causes of these disparities warrant further investigation.

Laparoscopic versus open hemihepatectomy: comprehensive comparison of complications and costs at 90 days using a propensity method.

Laparoscopic hemihepatectomy (LHH) may offer advantages over open hemihepatectomy (OHH) in blood loss, recovery, and hospital stay. The aim of this study is to evaluate our recent experience performing hemihepatectomy and compare complications and costs up to 90 days following laparoscopic versus open procedures. Retrospective evaluation of patients undergoing hemihepatectomy at our center 01/2010-12/2018 was performed. Patient, tumor, and surgical characteristics; 90-day complications; and costs were analyzed. Inverse probability of treatment weighting (IPTW) was used to balance covariates. A total of 141 hemihepatectomies were included: 96 OHH and 45 LHH. While operative times were longer for LHH, blood loss and transfusions were less. At 90 days, there were similar rates of liver-specific and surgical complications but fewer medical complications following LHH. Medical complications that arose with greater frequency following OHH were primarily pulmonary complications and urinary and central venous catheter infections. Complications at 90 days were lower following LHH (Clavien-Dindo grade ≥ III OHH 23%, LHH 11%, p = 0.130; Comprehensive Complication Index OHH 20.0 ± 16.1, LHH 10.9 ± 14.2, p = 0.001). While operating costs were higher, costs for hospital stay and readmissions were lower with LHH. Patients undergoing LHH experience a significant reduction in postoperative medical complications and costs, resulting in 90-day cost equity compared with OHH.

Preoperative continuity of care and its relationship with cost of hepatopancreatic surgery.

BACKGROUND: Continuity of care may be associated with health care outcomes and costs. The objective of the current study was to characterize the impact of continuity of care on perioperative outcomes, as well as on cost of care, among Medicare beneficiaries undergoing hepatopancreatic resection. METHODS: Patients with a minimum of 4 outpatient visits in the year before hepatopancreatic surgery were identified in the Medicare claims data. The Bice-Boxerman index was used to calculate continuity of care. The association of continuity of care and expenditures was assessed using a multivariable gamma regression with a log link. RESULTS: Among 25,698 Medicare beneficiaries who underwent a hepatopancreatic surgical procedure (hepatectomy: n = 10,679, 41.6%, pancreatectomy: n = 15,019, 58.4%), median patient age was 72 years (interquartile range: 68-77). Overall continuity of care was poor as the median continuity of care was 0.17 (0.10-0.29). Median total surgical costs were higher among patients in the lowest continuity-of-care quartile (continuity of care1st quartile: $25,500 [interquartile range, $18,100-$41,800]) compared with patients in the highest continuity-of-care quartile (continuity of care4th quartile: $22,700 [interquartile range, $17,100-$38,400]). Among patients undergoing hepatic resection, an increase in continuity of care of 0.2 was associated with decreased costs of 5.1% (95% confidence interval: -6.3% to -3.8%) compared with a decrease of 2.5% (95% confidence interval: -3.7% to -1.2%) among pancreatic resection patients. CONCLUSION: Continuity of care in the year before surgery was associated with total cost of surgery-including the cost of the index hospitalization and the total 90-day postdischarge costs. Relative to patients with a continuity of care = 0, indicating complete fragmentation of a patient's outpatient health care, patients with a continuity of care = 0.60 had 12.1% lower total surgical costs.

Robotic liver resection: Hurdles and beyond.

Laparoscopy is currently considered the standard of care for certain procedures such as left-lateral sectionectomies and wedge resections of anterior segments. The role of robotic liver surgery is still under debate, especially with regards to oncological outcomes. The purpose of this review is to describe how the field of robotic liver surgery has expanded, and to identify current limitations and future perspectives of the technology. Available evidences suggest that oncologic results after robotic liver resection are comparable to open and laparoscopic approaches for hepatocellular carcinoma and colorectal liver metastases, with identifiable advantages for cirrhotic patients and patients undergoing repeat resections. Excellent outcomes and optimal patient safety can be only achieved with specific hepato-biliary and general minimally invasive training to overcome the learning curve.

A comparison between robotic, laparoscopic and open hepatectomy: A systematic review and network meta-analysis.

BACKGROUND: The evidence of pairwise meta-analysis of Robotic Hepatectomy (RH) vs Laparoscopic Hepatectomy (LH) and RH vs Open Hepatectomy (OH) is inconclusive. Therefore, the aim of this study, was to compare the outcomes of RH, LH and OH by performing a network meta-analysis. METHODS: A systematic literature search was performed in the following databases: Pubmed, Google scholar, EMBASE and Cochrane library. Cost-effectiveness and survival benefits were selected as primary outcomes. RESULTS: The cost was less in OH compared to both minimally invasive procedures, LH demonstrated lower cost compared to RH, but the differences were not statistically significant. Both the RH and LH cohorts demonstrated significantly lower estimated blood loss, reduced major morbidity rate and shorter length of stay compared to OH cohort. The LH and OH cohorts demonstrated significantly shorter operative time and duration of clamping compared to the RH cohort. The LH cohort included significantly smaller tumours compared to the OH cohort. CONCLUSION: The present network meta-analysis, demonstrated that both RH and LH in malignant and benign conditions were associated with lower morbidity rates, shorter hospital stay and the procedure related costs were statistically nonsignificant between RH, LH and OH.

Simultaneous versus staged resection for synchronous colorectal liver metastases: A population-based cost analysis in Ontario, Canada - Health economic evaluation.

BACKGROUND: Simultaneous compared to staged resection of synchronous colorectal cancer liver metastases is considered safe. We aimed to determine their cost implications. STUDY DESIGN: Population-based cohort was generated by linking administrative healthcare datasets in Ontario, Canada (2006-2014). Resection of colorectal cancer and liver metastases within six months was considered synchronous. Cost analysis was performed from the perspective of a third-party payer. Median costs with range were estimated using the log-normal distribution of cost using t-test with a one-year time horizon. RESULTS: Among patients undergoing staged resection (n = 678), the estimated median cost was $54,321 CAD (IQR 45,472 to 68,475) and $41,286 CAD (IQR 31,633 to 58,958) for those undergoing simultaneous resection (n = 390), median difference: $13,035 CAD (p < 0.001). Primary cost driver were all costs related to hospitalization for liver and colon resection, which was higher for the staged approach, median difference: $16,346 CAD (p < 0.001). This was mainly due to a longer median length of hospital stay in the staged vs. simultaneous group (11 vs. 8 days, p < 0.001 respectively), which was not attributable to differences in major postoperative complication rates (23% vs. 28%, p = 0.067 respectively). Other costs, including cost of chemotherapy within six months of surgery ($11,681 CAD vs. $8644 CAD, p = 0.074 respectively) and 90-day re-hospitalization cost ($2155 CAD vs. $2931 CAD, p = 0.454 respectively) were similar between groups. CONCLUSION: Cost of staged resection of synchronous colorectal cancer liver metastases is significantly higher compared to the simultaneous approach, mostly driven by a longer length of hospital stay despite similar postoperative complication rates.

Assessing post-discharge costs of hepatopancreatic surgery: an evaluation of Medicare expenditure.

BACKGROUND: The true cost of liver and pancreatic surgery may not be completely ascertained by examining costs associated solely with the index hospitalization. We sought to assess post-discharge costs related to liver and pancreatic surgery after the index hospitalization. METHODS: We identified Medicare beneficiaries who underwent liver and pancreatic resection between 2013 and 2015. To assess post-discharge costs, costs were assessed for the following: all inpatient readmissions associated with an operative complication, follow-up outpatient visits with their operating surgeon, and use of skilled nursing facilities, hospice, and home health care within 90 days of discharge. RESULTS: Among the 21,737 patients who underwent either pancreatic or liver resection, the median cost of the index admission was $20,500 (interquartile range: $16,100-$34,300) (pancreas median: $22,100; interquartile range: $16,800-$36,500 vs liver median: $19,100; interquartile range: $15,100-$29,000). Approximately 30% (n = 6,435) had an all-cause readmission; more than half of readmissions (55.8%; n = 3,589) were related to an operative complication. Skilled nursing facilities and home health care services were utilized by 18.5% (n = 4,016) and 42.6% (n = 9,259) of patients, respectively. In total, nearly 75% of patients had additional, post-discharge hidden costs associated with their operative episode of care (n = 15,733: 72.4%). Male sex (95% confidence interval: 1.15-1.30) and black/African American race (95% confidence interval: 1.02-1.34) were associated with greater odds of post-discharge costs (both <0.05). CONCLUSION: Nearly 3 out of 4 patients who underwent a liver or pancreatic resection had post-discharge costs. Male and black/African American patients had greater odds of incurring post-discharge costs. As payers move to more bundled care payment models, strategies aimed at bending the cost curve associated with both the in-hospital, as well as the post-discharge setting, are needed.

Health-Care Workers' Perception of Reimbursement for Complex Surgical Oncology Procedures.

Perception of physician reimbursement for surgical procedures is not well studied. The few existing studies illustrate that patients believe compensation to be higher than in reality. These studies focus on patient perceptions and have not assessed health-care workers' views. Our study examined health-care workers' perception of reimbursement for complex surgical oncology procedures. An anonymous online survey was distributed to employees at our cancer center with descriptions and illustrations of three oncology procedures-hepatectomy, gastrectomy, and pancreaticoduodenectomy. Participants estimated the Medicare fee and gave their perceived value of each procedure. Participants recorded their perception of surgeon compensation overall, both before and after revealing the Medicare fee schedule. Most of the 113 participants were physicians (33.6%) and nurses (28.3%). When blinded to the Medicare fee schedules, most felt that reimbursements were too low for all procedures (60-64%) and that surgeons were overall undercompensated (57%). Value predictions for each procedure were discordant from actual Medicare fee schedules, with overestimates up to 374 per cent. After revealing the Medicare fee schedules, 55 per cent of respondents felt that surgeons were undercompensated. Even among health-care workers, a large discrepancy exists between perceived and actual reimbursement. Revealing actual reimbursements did not alter perception on overall surgeon compensation.

Socioeconomic determinants of the surgical treatment of colorectal liver metastases.

OBJECTIVE: We hypothesized that differences in resection rates of colorectal liver metastases exist based on socioeconomic status (SES) inequalities. METHODS: The NCDB was utilized to study patients of different median household income diagnosed with colon adenocarcinoma from 2010 to 2015. RESULTS: A total of 21,258 patients met inclusion criteria, of whom 3,587 (16.9%) underwent metastasectomy. Patients of the highest income quartile were more likely to undergo metastasectomy compared to the lowest quartile (OR 1.20, CI 1.07-1.37, p = 0.003). Overall, patients in the highest income quartile had a median OS of 17.1 months compared with 13.0 months for the lowest quartile (HR 0.85, CI 0.81-0.90, p < 0.001). While metastasectomy was associated with improved OS across all groups, the disparity by income quartile widened (29.2 vs. 22.0 months, respectively; HR 0.51, CI 0.49-0.54, p < 0.001). CONCLUSION: Higher income patients were more likely to undergo metastasectomy compared with lower income patients and were associated with longer OS.

Minimally invasive liver resection in the era of robotics: analysis of 214 cases.

BACKGROUND: Minimally Invasive Liver Resection (MILR) techniques range from a hybrid-technique to full robotic approaches. When compared with open techniques, MILR has been shown to be advantageous by reducing pain, complications, length of stay and blood loss. The aim of this study was to compare clinical outcomes and hospital resource utilization between full laparoscopic, hand-assisted, and robotic liver resections among major (≥ 3 segments) and minor (≤ 2 segments) resections. METHODS: A single-center comparative retrospective review was completed on 214 patients undergoing full laparoscopic, hand-assisted, or robotic liver resection procedures between 2005 and 2018. RESULTS: Among minor resections: 85 full laparoscopic, 40 hand-assisted, and 35 robotic liver resection cases were analyzed; and among major resections: 13, 33, and 8 cases were analyzed, respectively. In the adjusted subgroup analysis of minor resections, OR time was significantly longer for the minor hand-assisted group ([Formula: see text] = 181 min; p < 0.05), and the average lesion size was smaller for the minor full laparoscopic group ([Formula: see text] = 4.2 cm; p < 0.05). Overall, direct hospital charges were lowest in the group of patients who underwent a minor resection using the full laparoscopic technique ([Formula: see text] = $39,054.90; p < 0.05), compared to the robotic technique. Due to the smaller sample size (n = 54) in the major resection subgroup, only two significant observations were made - the full laparoscopic group had the least amount of blood loss ([Formula: see text] = 227 cc; p < 0.05) and incurred the least amount of room and board charges compared to the other two techniques. CONCLUSIONS: The robotic approach appears favorable for minor resections as evidenced by shorter length of stay but more costly than full laparoscopy. Clinical outcomes appear to be more dependent upon the magnitude of the resection (i.e. major vs. minor) than the MILR technique chosen. Randomized trials may be indicated to discern the best indications and advantages of each technique.

The hidden costs of open hepatectomy: A 10-year, single institution series of right-sided hepatectomies.

BACKGROUND: Incisional ventral hernias(IVH) are a common complication following open abdominal surgery. The aim of this study was to uncover the hidden costs of IVH following right-sided hepatectomy. METHODS: Outcomes and hospital billing data for patients undergoing open(ORH) and laparoscopic right-sided hepatectomies(LRH) were reviewed from 2008 to 2018. RESULTS: Of 327 patients undergoing right-sided hepatectomies, 231 patients were included into two groups: ORH(n = 118) and LRH(n = 113). Median follow-up-times and time-to-hernia were 24.9-months(0.3-128.4 months) and 40.5-months(0.4-81.4 months), respectively. The incidence of hernias at 1, 3, 5, and 10 years was 6/231(2.6%), 13/231(5.6%), 15(6.5%), and 17/231(7.4%); ORH = 14, LRH = 3, p = 0.003), respectively. In terms of IVH repair(IVHR), total operative costs ($10,719.27vs.$4,441.30,p < 0.001) and overall care costs ($20,541.09vs.$7,149.21,p = 0.044) were significantly greater for patients undergoing ORH. Patients whom underwent ORHs had longer hospital stays and more complications following IVHR. Risk analysis identified ORH(RR-10.860), male gender(RR-3.558), BMI ≥30 kg/m2(RR-5.157), and previous abdominal surgery(RR-6.870) as predictors for hernia development (p < 0.030). CONCLUSION: Evaluation of pre-operative hernia risk factors and utilization of a laparoscopic approach to right-sided hepatectomy reduces incisional ventral hernia incidence and cost when repair is needed.